Quote of the Day: Corpses and Carcasses in the Fields of Kursk
OKSANA LOBODOVA, who lives in Russia's Kursk region, recalling the Ukrainian cross-border invasion.
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New York Times
a day ago
- New York Times
Rebuilding Faces, Lives and a Sense of Self in Ukraine
After more than three years of war, thousands of Ukrainians struggle with the physical and emotional trauma of severe facial injuries. Doctors use cutting-edge methods like 3-D printing to rebuild faces. 'I want to live,' said Nelya Leonidova. 'For my children, for the life that was stolen but not lost. I want to find peace in the pieces left to me.' Recovery is grueling, with wounds that impair eating, speaking and even the sense of self. Patients depend on doctors to heal their physical wounds, and on the support of family to move forward. Supported by By Marc SantoraLaetitia Vançon and Daria Mitiuk Photographs by Laetitia Vançon The face is the window to identity and emotion. To have it disfigured is not merely to be wounded, but to be unmoored from one's own sense of self. Since Russia's invasion of Ukraine in 2022, many Ukrainians have suffered grievous facial injuries, a brutal testament to the power of modern weaponry and the vulnerability of the flesh. 'A soldier loses a leg, and society calls him a hero,' said Dr. Andrii Kopchak, the head of the department of maxillofacial surgery at Bogomolets National Medical University in Kyiv. 'But lose your face? You become a ghost.' Surgeons have made significant strides in tending to Ukraine's wounded, particularly through the use of 3-D printing. By creating patient-specific implants and surgical guides, the technology allows for more precise reconstruction of shattered jaws, cheekbones and eye sockets — restoring not just function, but the very contours of someone's identity. These advances build on a century of innovation, from Harold Gillies's pioneering surgery to mend faces broken in the muddy trenches of the Somme in World War I to today's digital modeling to repair bodies mangled in the bloody battle for Bakhmut. The goal has long been to restore function, while also giving hope to the wounded. For many of Ukraine's wounded, breakthrough surgical treatments followed earlier, botched operations that, in effect, had to be undone and redone. Like much of the Ukrainian war effort, the medical struggle has been marked by improvisation and experimentation. The New York Times spent two years visiting men and women whose lives have been shattered, and meeting the doctors and volunteers working to help them. Battling to Return to Battle 'It's the same fight, for yourself, for your life,' said Volodymyr Melnyk. 'Just like in the trenches, same goes for the hospital bed after the injury.' Throughout his recovery, Mr. Melnyk was driven by one burning desire: to rejoin the fight. Ukrainian and foreign surgeons have made significant strides in tending to the wounded. Doctors said that the psychological scars can be even harder to heal. Mr. Melnyk, 32, was wounded in 2023, when his unit stormed a Russian hilltop position and, after intense combat, seized control of it. During the battle, shrapnel shredded his face. 'All the nerves on the right side of my face were severed,' he said. 'All the bones were shattered. I could not see out of my eye.' The evacuation team could not reach him at first. Russian artillery and drones made movement impossible. For nearly 23 hours, he fought on through the pain. 'When you're in an enemy trench, you have two options: either sit down, pity yourself and die, or do everything you can,' Mr. Melnyk said. Once he reached safety and the adrenaline was gone, the cruel reality of his injuries set in. He said some of the nurses who saw him early on had the attitude, 'You're going to die anyway,' and showed no interest in treating him. After the Napoleonic wars, soldiers described killing comrades with mutilated faces, justifying their actions by saying that death was better than living with such misery. In World War I, soldiers who survived facial trauma were often shunned by society — a stigma that doctors in Ukraine said exists today. Mr. Melnyk underwent round after round of surgery. Plates were incorrectly placed, abscesses formed, and shrapnel was left inside. It was only after nearly two months that volunteers from the 'Doctors for Heroes' project intervened, helping transfer him to a new hospital and a new program to reconstruct his face. 'We scan the skull, create a digital model and print titanium plates layer by layer,' said Dr. Kopchak, pulling up a CT scan of a patient's smashed jaw. 'It's like rebuilding a shattered vase. Every fragment matters.' Mr. Melnyk has endured more than 50 operations. Last fall, he was preparing for what he hoped would be the last. 'The main thing was to be able to chew and eat because that's energy for a person, especially a soldier,' he said. He has since returned to duty at the front. No Place Is Safe Artur Tkachenko returned from the front, hoping he had put the worst of the war behind him. The war followed him home, where a Russian missile killed his parents. The blast severely injured Mr. Tkachenko, leaving his face all but unrecognizable. With state resources stretched, family support and volunteers have been vital to him and other survivors. As the father of young children, Mr. Tkachenko, a factory worker, was not required to do military service. But he enlisted after Russia invaded, and he spent months in brutal combat before returning to his village, Novosofiivka. It was just weeks later, when he, his wife, Julia, and their 20-month-old daughter were visiting his parents, that the missile struck. The explosion that killed his parents also injured his wife and daughter, hurling the little girl more than 20 yards. When he regained consciousness, Mr. Tkachenko, now 37, did not recognize the face in the mirror. 'It was very different,' he said from a hospital bed in Kyiv, still struggling to find words. 'I couldn't feel parts of it. I couldn't even talk.' He had suffered severe damage to his skull and facial bones. 'Shrapnel was embedded deep inside his head — one piece was even protruding when he arrived,' said Roman Kozak, the surgeon who performed the initial reconstructive surgery last year. It was an exceedingly complex case, the doctors said, that showed both the possibility and some limitations of technology. Dr. Kozak and his team collaborated with bioengineers to digitally reconstruct Mr. Tkachenko's shattered face. With 3-D printing, they created implants tailored to his unique facial structure, to hold bone fragments in place. 'Now, we are preparing for a second surgery to reconstruct his lower eyelid and remove the metal plates, which pose a risk of infection due to their proximity to the nasal sinuses,' Dr. Kozak said. Back From the Dead Nelya Leonidova is determined to help others who have suffered wounds like hers. Early in recovery, 'there were times I thought about ending it all,' she confessed. Now, she wants to devote her life to helping others who are grievously injured. It has been a hard road, she said, but she has found both new love and renewed purpose. The first thing Ms. Leonidova, now 45, remembers after being injured was the feel of cold steel pressing against her cheek. She did not know where she was, only that it was dark and a stench hung thick in the air — a mix of antiseptic and death. All around her were corpses. 'I was taken as 'cargo 200,'' she would later recall, using the military code for the dead. She had been mistaken for another fatality from shelling that tore through her small town in eastern Ukraine in 2014, during the opening chapter of what would grow into the deadliest war in Europe in generations. She soon fell into a coma, waking after two months. Her right eye was gone, her jaw shattered, her body scarred. 'I couldn't understand anything,' she said. Before the war, life in Zuhres, her village near the Russian border, was marked by simple pleasures. She was a mother and a factory worker, tending flower beds between shifts at the plant. 'Our whole region is filled with roses,' she recalled. 'The fragrance of cherry blossoms, the Blue Lake, the quarries, the river. It all inspires you.' In early 2014, violence engulfed her region, known as the Donbas. Russia fomented a separatist uprising in the Donbas, where militias aided by Moscow began seizing territory. She held her children close and hoped to ride out the turmoil. She was returning from a chicken farm to distribute food to local residents when Russian warplanes bombed the road. 'My first thought, piercing like pain, was 'the children,'' she said. 'Dying isn't scary; I know that now,' she added. 'The fear is leaving your children alone in this world.' Her children later escaped Russian-occupied territory, joining her first in Kharkiv and now in western Ukraine. She has undergone countless surgeries, many to correct earlier operations. Doctors from the American charity Face the Future used a titanium implant, tailor-made, to rebuild her shattered eye socket. Ms. Leonidova now wants to study psychology and open a center to help others wounded in war. Her darkest thoughts have faded. She and her boyfriend, Nazar Zhurba, got engaged. 'I'm a tough woman — titanium facade, steel bite, and the stare of a pit bull after a fight, creating miracles like Medusa Gorgon,' she said with dramatic flourish. 'My gaze turns people to stone.' Not Wanting to Be Seen After an exploding mine tore apart his face, Bohdan Poplavskyi did not want his sons to see him. It is common, doctors said, for patients with traumatic facial injuries to want to close themselves off. Patients who are unrecognizable to themselves can find it hard to reclaim their place in society. Mr. Poplavskyi's progress has been slow — he still cannot talk and has little sight. Mr. Poplavskyi struggles most with the loss of vision, his family said. He was eventually reunited with his sons, who often guide him through the world, and it pains him that he cannot see them or watch them grow up. For such patients, 'the psychological toll is relentless,' Dr. Kopchak said. 'Imagine looking in the mirror and not recognizing yourself. Now imagine your wife or child seeing you that way.' He has watched marriages collapse and families fracture. 'We have one psychologist for hundreds of soldiers,' he said. 'He's a good man, but he wasn't trained for this.' International collaboration has been a lifeline, he said. Finnish surgeons traveled to Kyiv to perform complex nerve grafts. French experts shared protocols for orbital reconstruction. The group 'Face to Face' played a critical role. Mr. Poplavskyi's first surgery last year took 17 hours. 'We are coping because of the doctors,' his sister, Dina Yakubenko, said. Medical teams are preparing to use stem cell therapy, hoping to improve his vision. Despite all the suffering, his family said, Mr. Poplavskyi, now 40, remains mentally stable and, most importantly, they are together. 'We are his psychological support,' his sister said. 'And we are the psychological support for each other.'
New York Times
2 days ago
- New York Times
Bite Club: The Fraternity That Awaits You After a Shark Attack
It was from a hospital bed, in a daze from painkillers, overwhelming media attention and a lingering frisson from her brush with death, that Anika Craney saw the Facebook message: 'Welcome to Bite Club.' Days earlier, she had been free-diving in the Great Barrier Reef when she saw a shark barreling toward her. She flipped around to put her fins between herself and the predator, but the murky water around her quickly turned crimson. Blood coursing out of her left foot, she struggled to get to the beach, trying to stem the arterial bleeding and screaming for help. An off-duty medic fashioned a tourniquet out of a belt, saving her life and her limb. Even in those early moments, Ms. Craney, then 29, was determined not to let the experience affect her lifelong bond with the ocean. From a gurney, as she was taken from the rescue helicopter into the hospital, she cried out to a swarm of news cameras: 'I still love sharks!' What she didn't know was that the bite was the beginning of a long journey. Yet to come were searing nerve pain, nightmares, sleepless nights, hallucinations and the loneliness of suffering from physical and psychological wounds that few can relate to. Still ahead were the offers of quick money for an interview or a documentary, which would only renew her trauma and underscore that the world's interest was in the gruesome details of her encounter, not the grueling recovery that would never truly be over. But Dave Pearson knew — because he had been through it a decade earlier, after a shark shredded his left forearm down to the bone, profoundly altering his life and his mind. So he reached out to Ms. Craney, as he has for many other survivors in the years since his own bite, welcoming her into a fellowship no one would want to join. Over the phone, in his calm, steady voice, he told her a bit about what to expect, and he said there was a group of people she could turn to. 'We've been through this and we're here for you, through every step of the way,' she later recalled him saying. 'Why Me?' There is a pattern, Mr. Pearson has learned, to what comes after the bite. There is the elation of survival, the celebration of a miraculous escape, the inundation of attention. Then, often, comes months of obsession, spent researching everything about the creature and its behavior. 'You just want to know, why me? What did I do wrong?' he said. 'The hardest thing to accept is you did nothing, you were just in the wrong place at the wrong time.' Mr. Pearson, 62, is the founder of Bite Club, a network of shark attack survivors (plus family members, first responders and a few people who've been bitten by other animals, like crocodiles). It started in Australia but now has more than 500 members across the world. Its private Facebook page functions as a medical forum, a middle-of-the-night lifeline, a post-traumatic stress disorder support group and an accidental family. It is an exclusive club, one with many members in Australia, where the vast majority of the population lives near the coast (the country regularly reports more human-shark encounters than any other, except for the United States). Last year, 47 'unprovoked' shark bites were reported worldwide, four of them fatal. Mr. Pearson, an affable Everyman with the sunbaked hue of a lifelong surfer, joined those rarefied ranks in 2011. During an afternoon surf at his local beach at Crowdy Head, a few hours up the coast from Sydney, a bull shark sank its teeth into his brand-new surfboard — and his left arm, including the wrist and the hand. His buddies pulled him out of the water and tried to slow the catastrophic bleeding with a tourniquet, using his surfboard leash. Lying on a beachside picnic table, he cracked jokes and admired the sunset while waiting for a helicopter to arrive, thinking it was not such a bad day to die. When he emerged from surgery, he was ecstatic to see that his arm had not been amputated. Once the blur of the first weeks was over, though, a quiet new reality set in. There were long days alone, addled by painkillers, and fraught nights during which scenes from the fateful day replayed in his dreams. He could not turn to the one place where he'd always sought solace: the ocean. 'The shark decided to upturn that basket where I've been hiding everything my whole life,' he said. 'I thought I was doing really well, until I wasn't.' During his time in the hospital, he met a young woman about his daughter's age, who had been bitten a week before he was. He was amazed at the instant connection they felt. Mr. Pearson began reaching out to every shark attack survivor he could get in touch with — calling hospitals, asking journalists to put him in touch, talking to local government officials who worked on shark safety. He started calling survivors regularly on his commute, sometimes driving for hours to meet them in person. When he realized there was no place where they could share their experiences and exchange information and advice, he thought: 'Let's become that group that just supports people.' His first idea for a name, Australian Shark Attack Survivors and Friends, was a mouthful. 'Bite Club' came up as a joke in a late-night conversation over beers and wine. It was snappier. Someone to Talk to Most discussions of human-shark encounters are accompanied by the caveat that they are exceedingly rare. People are more likely to be killed by bee stings or lightning strikes, and getting bitten by another human is far more common. But there's a flip side to that: If you do have a run-in with a shark, very few people know what you're going through. Ms. Craney is a lifelong swimmer and diver who, as a child, doodled dolphins in every textbook and daydreamed about becoming a mermaid. She was living on a boat off Australia's eastern coast, working on a film crew for a series about the Coral Sea, when a quick swim with a colleague to look for sea turtles ended with the bite. Not long after speaking with Mr. Pearson on the phone, she introduced herself on the Bite Club Facebook page. 'Hi, my name's Anika and I was just bitten by a bull shark in Far North Queensland,' she recalled writing. 'I was bitten on the left leg, and I've got this damage, deep and superficial peroneal nerve damage, three tendons severed, dented tibia bone and a tooth shattered in my bone.' Her nerve pain was harrowing — 'It feels like you're being electrocuted, or like you've got red ants biting you all over your skin' — but psychologically, she thought she was one of the lucky ones. Many survivors never go back into the ocean; some can't even bear to face it, sitting at the beach with their backs turned to the water. But within a couple of months, Ms. Craney was back in, swimming and diving. She went to work as a skipper for a boat charter company. A little more than a year after her attack, while surfing with Mr. Pearson and his partner, Debbie Minett, she dove under a wave and saw, crystal clear, a shark with its mouth agape, hurtling toward her. 'I blinked, and it disappeared,' she said. It had been a hallucination, vividly imprinted into her brain. 'I burst into tears and called out for them,' she said. 'I said, 'I need to get out, I need to get out.'' At work, she began hearing phantom cries for help, or people yelling, 'Shark!' She had to give up the job. At night, the image of the approaching shark would play on a loop in her mind. On those nights, she would turn to the Bite Club page to see if anyone was awake, someone she could talk to. There always was. 'The mental hurt becomes louder when you feel alone, but when you can relate to other people, you don't,' she said. 'It's honestly lifesaving.' An Affinity, an Understanding Earlier this year, at the tail end of Australia's summer, Mr. Pearson went to Bondi Beach in Sydney to meet with Andrew Phipps Newman, who was bitten by a shark in the Galápagos Islands in 2018. Bondi's pristine sand and water were brimming with sunbathers, swimmers and surfers. Mr. Phipps Newman found himself constantly scanning the waters for dark shadows. He was in Sydney on a business trip from Britain, and Mr. Pearson and Ms. Minett had driven four hours south to see him. It was the first time the men had met in person, but they immediately embraced in a bear hug. Another Bite Club member, a young woman who was attacked last year, briefly stopped by to say hello. 'You're both leg people,' Mr. Pearson told them. 'You just have an affinity. There's a warmth, there's an understanding,' said Mr. Phipps Newman, who had met only one other survivor in person before, back home in Britain, through Bite Club. Mr. Phipps Newman had been reeling from his husband's unexpected death when he joined the Galápagos snorkeling excursion on which he was bitten. When he felt the powerful force pulling him down, he thought a fellow tourist was playing a joke. Instinctively, he punched the shark in the nose twice, and it let him go. In that moment, he said, for the first time in months of wallowing in grief, he felt a strong will to live. He had stayed away from the ocean in the seven years since then. On this day, though, at Mr. Pearson's urging, Mr. Phipps Newman took his socks off and waded briefly into the water, up to his shins. Bite Club members often accompany one another for their first return to the ocean, or for a swim or a surf to mark the anniversary of their attack. Mr. Pearson has a nearly encyclopedic knowledge of club members' injuries, and he connects people who he thinks will benefit from speaking with each other, almost like a sponsor in a recovery group. He put Ms. Craney's father in touch with an American whose daughter had also been attacked. The two men, both of whom joined Bite Club, had suffered from nightmares, fear of the ocean and a paralyzing dread for their daughters. A few club members are people who lost relatives to shark encounters — reminders, to the others, of how easily their stories could have ended differently. Some of those members have asked survivors about the pain they suffered, wanting to know what their loved ones' final moments were like, Mr. Pearson said. He assured them that in the first 20 minutes of the experience, with adrenaline coursing through his body, he felt absolutely nothing. Back in the Water Last month, Ms. Craney marked the fifth anniversary of her attack. She is back in the water, swimming and diving. She recently moved from Sydney back to Cairns, near the site of her bite, to be closer to the ocean she loves. She is also starting a business, teaching diving to people who struggle with trauma. On her drive up, she stayed with Mr. Pearson and Ms. Minett at their home in Coopernook. They went for a quick swim at Crowdy Head, where Mr. Pearson was attacked, near where she hallucinated. She peeled off socks that featured cartoon sharks and, on the soles, the words 'BITE ME.' Looking out at the waves he's surfed for five decades, Mr. Pearson said that his attack, more than 14 years later, still colored his every encounter with the ocean. 'I used to stare at the waves, thinking of how I would ride each one,' he said. Now, each surf is tinged with fear. But he swallows it and paddles out, several days a week. How long does an attack stay with you? A few years ago, Mr. Pearson got a call from a staff member at a nursing home, who asked if he would meet with a resident in his 80s. The man, who had Alzheimer's, was experiencing night terrors that seemed to stem from his experience with a shark. The man had been attacked in 1955. Mr. Pearson visited him twice, listening to his story, as he does for new members of Bite Club. Even though the man couldn't remember Mr. Pearson's name on the second visit, he recounted the details of his attack as if it had just happened. Their chats seemed to bring the man peace, and his nights were calmer after that. For Mr. Pearson, that's what it's all about. What he has lost in his uncomplicated love for the ocean, he has gained in profound connections with hundreds of people around the world. 'You get to make a difference,' he said. 'We share this thing.'
Yahoo
3 days ago
- Yahoo
‘Cult' of tourniquets causing thousands of unnecessary amputations and deaths in Ukraine, say surgeons
The tourniquet has saved many thousands of lives and limbs in war zones around the world, but misuse of the device is causing huge numbers of excess amputations and deaths in Ukraine, say top military surgeons. Captain Rom A Stevens, a retired senior US medical navy officer who has served in Iraq, Afghanistan, and East Africa, estimates that of the roughly 100,000 amputations performed on Ukrainian soldiers since Russia's full-scale invasion in 2022, as many as 75,000 were caused by improper use of tourniquets. 'I've seen tourniquets that have been left on for days, often for injuries that could have been stopped by other methods. Then [the patient] has to have their limb amputated because the tissue has died,' Captain Stevens told The Telegraph. Tourniquets are strong bands used to stop catastrophic bleeding by cutting off blood flow, and are standard issue for most modern armies. But if left on over two hours, they can cause tissue death, meaning the arm or leg which has the tourniquet on is no longer viable and requires amputation. The device became standard-issue in the 2000s wars in Iraq and Afghanistan, where rapid air evacuation to military surgical teams was possible in under 60 minutes. If the tourniquet was unnecessary it was removed, and no harm was done. But in Ukraine, where the skies are infested with drones, injured soldiers are evacuated by land, often far exceeding the safe time window for tourniquet use. This critical delay has caused tens of thousands of amputations, say experts, many of which were unnecessary because the injuries didn't require a tourniquet in the first place. It has also led to a sharp rise in young Ukrainians needing dialysis, said Captain Stevens who has served as a medical volunteer in hospitals in Zaporizhzhiya, Dnipro, and L'viv since the invasion in 2022. This is because when a tourniquet is removed after being kept on too long, toxins from dead tissue flood the bloodstream, overwhelming the kidneys. Captain Stevens helped draft the US military guidelines for tourniquet use and now wishes greater emphasis had been placed on assessing when they were needed to stop bleeding. He fears that their successful use in wars where rapid evacuation was possible has led to a 'cult-like' dependence on a tool that should be used much more sparingly. In Ukraine, it has left 'a generation of men traumatised by unnecessary amputations,' he said. The US Tactical Combat Casualty Care (TCCC) handbook was created for trained military medics operating in war zones in the 1990s and heavily promotes the use of tourniquets in war, describing their use as 'the best method to control life-threatening bleeding'. Widely adopted by NATO and Western armed forces in the early 2000s, the TCCC standards were quickly integrated into Ukrainian military and civilian medical training following the Russian invasion of Crimea in 2014. Captain Stevens – though an author of the TCCC – says this was a error. 'If you have a perfect battlefield, then tourniquets work. But if you don't – if you have a situation like Ukraine today – you can end up with a tragedy. And that's what the Ukrainians have,' he said. 'There's now hundreds of thousands of tourniquets that have been distributed to military forces, civilians, fire departments, and police in Ukraine. It's become a cult, and because it saved lives in Iraq and Afghanistan, people think it's a good idea,' he added. While most Western militaries embed specialist medics in every unit, Ukraine's armed forces – made up largely of conscripts and civilian volunteers – often rely on medics with only a few weeks or even days of training who are often unable to distinguish between injuries that do and don't require tourniquets. 'The Ukrainian infantry and artillery battalions are undermanned. They can't replace their medics when they get injured or killed,' Captain Stevens said. A 2022 study by a Ukrainian military vascular surgeon, Dr Vladyslav Yatsun, found that only 24.6 per cent of war wounded patients arriving at hospital with tourniquets had injuries that justified their use to stop bleeding. 'In all other cases, the use of pressure bandages was more appropriate,' the study said. They are also often being applied too high on damaged limbs, said Captain Stevens. 'They are often taught to place on the tourniquets well above the wounds, and the result is a very high amputation, making it difficult to later fit a prosthesis,' he said. An updated version of the Ukrainian TCCC disseminated to the armed forces in January 2024 specifically reads: 'Place the tourniquet 'high and tight' on the wounded extremity.' NATO has also raised concerns about tourniquets in Ukraine. Last year, the agency dispatched a team of medical and military experts to investigate what it described as 'an unacceptable high complication rate from the use of tourniquets [...] resulting in amputations, renal failure and even death.' The organisation added: 'The current situation with prolonged evacuation times requires a shift in attitude towards tourniquets,' although it has yet to formally publish its recommendations. Experts stress that tourniquets continue to save many lives and should not be abandoned. Instead, they say that in places like Ukraine where rapid evacuation is difficult they should only be used in the three circumstances in which they are absolutely necessary. The first is when a limb has been completely severed. 'In that situation, you need a tourniquet, but you need to put it as low down as possible to try and save as much of the limb as you can,' said Captain Stevens. The second is when the limb is so damaged that it cannot be saved – a decision that requires judgement and medical third is when a person has uncontrolled arterial bleeding that cannot be stopped with direct pressure or any other method. Captain Stevens said tourniquets are often applied by panicked soldiers, who lack the knowledge or confidence to try other methods first. 'When a [Ukrainian] soldier is injured in the field, they're usually taken care of by other soldiers in a panic,' he said. 'They see blood. They put on tourniquets because they have tourniquets. We gave them tourniquets.' Dr Ostap Zubach, an orthopaedic surgeon who works at a major trauma hospital in L'viv, agrees that while tourniquets can be life-saving, they can also be deadly when used incorrectly. 'As a doctor, I believe that in the right hands, tourniquets are a brilliant thing. But in the wrong hands, they can be very dangerous,' he said. A particular problem was that many soldiers did not know how to temporarily loosen a tourniquet periodically to extend the time of safe use. 'The strategy of tourniquets [in Ukraine] is just not working, especially when [the soldiers] don't know how to convert them,' said Dr Zubach. 'Many of our soldiers have no experience in the military or medicine.' Major General Anatoliy Petrovych Kazmirchuk, Commander of the Medical Forces of the Ukrainian Army, introduced tourniquet 'conversion' into the basic military training programme last year following reports of excessive amputations and limb loss at the front. But both Captain Stevens and Dr Zubach are sceptical on what impact the new training is having. 'The problem is that under fire, people are afraid to take the tourniquets down. They're in a rush to get that patient to a hospital surgeon and don't stop to convert them,' said Captain Stevens. A growing group of medics both in and outside of Ukraine are now putting pressure on the ministry of defence to move away from the TCCC handbook and develop their own set of medical guidelines for use in the Ukrainian context, factoring in long evacuation times. 'Guidelines are only guidelines. They require common sense to apply, they require professional judgement. In Ukraine, they don't have a system for developing guidelines. Often they just take Western, US, British, NATO guidelines, and translate them, word for word into Ukrainian,' said Captain Stevens. 'But there's a lot of resistance to changing it. The Ukrainians are taking their cue from the Americans, but our protocols were not designed for this situation,' he added. 'If you go back to World War Two and you read what the American theatre surgeons had to say about tourniquets, they said they were dangerous because they were often placed on wounds that did not require them, and then not taken off before it was too late,' he said. 'You didn't have a rapid evacuation there either. You're evacuating by land, over bumpy roads, in the middle of the night under fire, just like what the Ukrainians are doing now.' Both Dr Zubach and Captain Stevens say more emphasis needs to be put on basic casualty care, like cutting off clothes to examine the wound to see the source of bleeding, use of pressure bandages, and alginates – jelly-like dressings that can absorb heavy bleeding and pack into wounds without the long-term risks associated with a tourniquet. Both agree that tourniquets should be used only as a last resort, when all else has failed. 'Soldiers and medics need to understand that when a tourniquet is placed on the Ukrainian battlefield, it usually means an amputated limb,' says Stevens. Protect yourself and your family by learning more about Global Health Security
